Bukekan Karate Dojo Registration Form* Please complete all fields and click Submit at the bottom of this form.

Choose Month to Begin Training *

Please click on the Dojos Tab to view the Schedule for your child's school. Please select the appropriate month your child will be attending.

Parent Information *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

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Cell Phone Number *

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Email Address *

Confirm Email Address *

Payment Method *

MasterCard® and Visa® credit cards can only be accepted in person. Please call to make arrangements by calling Sensei Thomas, (815) 351-1923. If you pay by check, please make your check payable to Wayne Thomas.

Dojo Location *

Student's Name *

First

Last

Grade *

Gender *

Physical and/or Behavioral Concerns *

From a teacher/instructor perspective, is there anything I should be aware of?